Provider Demographics
NPI:1013544840
Name:EDMISTON, BREANNA (PA-C)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:EDMISTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5240 WEBB ST
Mailing Address - Street 2:
Mailing Address - City:ALIQUIPPA
Mailing Address - State:PA
Mailing Address - Zip Code:15001-4946
Mailing Address - Country:US
Mailing Address - Phone:412-849-6849
Mailing Address - Fax:
Practice Address - Street 1:1030 BEANER HOLLOW RD
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:PA
Practice Address - Zip Code:15009-9722
Practice Address - Country:US
Practice Address - Phone:724-775-4242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-23
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA059675207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery